Cardiac Resynchronisation Therapy
Experience From Clinical Cases
Dr Nizam Domah , Dr Deva Chellen, Dr S Deenoo
Victoria Hospital
Clinical Case 1
• Female 62 yrs
• 1st admission 03/06/2004 with Hx of sudden
onset of Acute SOB c Palpitations.
• Dyspnea with Orthopnea ++.Gallop rhythm
Bilateral Crepts +++
• PMH : DM, HTN, Hyperlipidemia - Nil
• No h/o of anginal pain.
• BP 130/80mm/hg
• ECG : NSR, HR 120/min
•
LBBB with large QRS complexes
• Treatment started :
Classical treamt for APO :
loading dose diuretics ; IV nitrates ..
• Portable CXR : Gross Cardiomegaly
pulmonary venous congestion
• Bed side Cardiac Echocardio :
Features of DCM with poor LVEF 20%;
Globulous LV with global hypokinesis ,
left atrium not dilated;
MR GD 1 ,
estimated PAP 45mmhg.
Valves are normal .
Blood investigations :
Troponin NEGATIVE.
Random blood sugar 6.3 mmol
Urea & Electrolytes – Within normal range
Free T3 T4 TSH… all normal.
• Further Investigations !
• Once patient dry….
Coronaro angio: Normal Arteries
• Most likely aetiology Idiopatic
Cmyopathy. Viral ??
• Discharged on D6 on ACE inhib.,
Diretics, Nitroglyceri Patch ( to reduce
pre-load ) , carvedilol , anti vit K ..
• Re admission within 1 wk with relapse of pulm
oedema ..
• Confirms that meds prescribed were regularly
being taken.
• Treatment were revised and diuretics titrated up.
• Patient stayed this time for 4 days and
discharged on same except higher dose of
diuretics..
• Since then patient has been admitted very
regularly and no more responding to maximal
medical treatment…..
Pt still symptomatic:
NYHA III/IV orthopneic.
WHAT NEXT…
Mx Options in Refractory Heart Failure
DEVICE THERAPY
SURGICAL
•CRT
•ICD
•CRT-D ( Combo Device)
Revascuarization
Mitral Valve repair/
replacement
LVaDs
Cardiac transplant
TAH
Stem Cell Therapy
LV remodeling surgeries
(Batista or Dor’s procedure
Others : Ultrafiltration(Peritoneal Dialysis)
Corcap
Background CRT
One of the most successful heart failure therapies to
emerge in the last decade and is applicable to 25–30%
of patients with symptomatic heart failure
Restores the coordination of contraction and
relaxation among the cardiac chambers,
which leads to
• reverse ventricular remodelling,
• improved exercise tolerance,
• less heart failure admissions and
• decreased mortality
Dyssynchrony
• AV- delay
• Prolonged AV interval → delayed systolic
contraction of LV →impairment of early diastolic
filling
LA diastolic pressure < LV diastolic pressure→
diastolic MR
↓LV preload → ↓ contractility
• Inter- and intra-ventricular conduction delay
( ventricular dyssynchrony)
asynchrony contraction →↓efficiency of contraction→↓
stroke volume
Uncoordinated papillary muscle→ agravation of functional
systolic MR
Resynchronization
• Restores AV, inter- and intra-ventricular
dyssynchrony leading to:
1. Improvement of LV function
2. Reduction of functional MR
3. LV reverse remodeling
↑ LV filling time
↑ LVEF
↓ EDV & ESV
↓ MR
↓ dyskinesia
Methods of patient assessment prior to CRT implant
Assessment
ECG
Echocardiogram
Goals
QRS duration and morphology
rhythm, PR interval, P-wave
morphology
Ejection fraction, LV size, MR, RV
function
Functional testing (6 min
Baseline objective functional status
hall walk test or CPX)
Basic
requirements
History and physical
exam
NYHA symptom class,
comorbidities, life-expectancy, risk
for altered venous anatomy,
suitability for procedure
Serum chemistries
Electrolytes and renal function,
coagulation tests
Medication usage
Maximally tolerated doses for
appropriate duration. Include
diuretic evaluation for volume
status
Mechanical dyssynchrony by
echo
Type and extent of
dyssynchrony
Stress echocardiography
Assess ‘recruitable’
myocardium
Cardiac CT angiography
Great cardiac vein and
branch mapping, CS
ostium, LVEF, chamber
sizes
CMRI
Great cardiac vein and
branch mapping, CS
ostium, LV tissue
characteristics including
infarct area, LVEF
QOL measurement
Baseline measurement for
future comparison
Additional
evaluations:
optional
Cardiac Resynchronization Therapy in
Patients With Systolic Heart Failure
I IIa IIb
IIbIII
III
I IIa IIb
IIbIII
III
CRT is indicated for patients who have left ventricular
ejection fraction (LVEF) less than or equal to 35%, sinus
rhythm, LBBB with a QRS duration greater than or equal to
150 ms, and NYHA class II, III, or ambulatory IV symptoms
on GDMT. (Level of Evidence: A for NYHA class III/IV; Level
of Evidence: B for NYHA class II).1
I IIa IIb
IIbIII
III
CRT can be useful for patients who have LVEF less than or
equal to 35%, sinus rhythm, LBBB with a QRS duration 120
to 149 ms, and NYHA class II, III, or ambulatory IV
symptoms on GDMT.2
I IIa IIb III
CRT can be useful for patients who have LVEF less than or
equal to 35%, sinus rhythm, a non-LBBB pattern with a QRS
duration greater than or equal to 150 ms, and NYHA class
III/ambulatory class IV symptoms on GDMT.2
CRT Implantation
CRT.
1, Pacemaker
generator;
2, right atrial
pacer wire;
3, right
ventricular pacer
wire;
And
4, coronary
sinus (“left
ventricular”)
pacer wire.
Back to Clinical Case 1
Female 62 yrs
DM, HTN, IHD - Nil
DCM with poor lvf 20%
LBBB with large QRS
Refractory despite guideline-directed medical
therapy (GDMT)
So …. She fits in..
OUTCOME POST IMPLANT
Clinical outcome post implant:
•Drastic improvement within 2 wks : NYHA I
No orthopnea ;
•Progressively resume normal activities ;
Diuretics tailored off .
•ECG –Fine QRS complexes
•ECHO LVEF 40-45 %
•Present Meds :Carvedilol 25 mg bd ;
Ramipril 5 mg od..
•No Admission since implantation (2009)
Pre CRT showing Wide QRS Complexes
Post CRT
Showing fine
QRS complexes
Clinical Case 2
•Male 57 yrs
• Acute AWMI 1992 ( Thrombolysed)
•CAG 1997 : LAD Non signf lesion ,
Med Rx
•
LCX & RCA Normal
•19/10/2000 Admitted c VT
DC Shocked *5times
•
•
NSR , HR 73/min
• 25/10/2000
VT ,Fits DC Shocked *5times
Stable on Med Rx for 5yrs
06/06/2006 VT DC Shocked150/200J *3times
Cardiac Echo : Dilated LV c EF 20%
Akinetic Septum
Further Management !
• RE-Coronary Angiography:
Minor lesion LAD, LCX, RCA Normal
• Optimal Med Rx :
Carvedilol , Aldactone,Cordarone , ASA , ATV
• Still having episodes of VT
Benefited from CRT –D
No Admission since implantation
Device Monitoring
Thank You